975

THE MEDICAL EXAMINATION OF THECIVILIAN AERONAUT.1

AN explanation of the methods and standards now inuse in this country for the examination of applicantsfor licences as civilian airmen was published, at theend of last week, under the authority of the Air Council.The Dominions and Colonies, who are now about to putinto practice the principles laid down in the Inter-national Air Convention, have been especially in the eyeof the Air Council in issuing a valuable brochure, but allthe medical profession, and, indeed, the public, willbenefit by learning the careful procedure whereby theintending aeronaut is selected for his dangerous andresponsible career.The pamphlet begins by reference to the

Interncetionab MecMca-! Requirements for Air Navigation.An extract from the Convention relating to Inter-

national Air Navigation, 1919, is quoted, setting out thatthe requirements are that pilots and navigators engagedin public transport shall be 19 years of age, of goodfamily and personal history, free from mental, moral,or physical defect or hereditary nervous instability, andable to reach the standards required at a generalmedical and surgical examination and also at examina-tions into special sense acuity. The InternationalConvention sets out that-

(1) Every candidate before obtaining a licence as a pilot,navigator, or engineer of aircraft engaged in public transport shallpresent himself for examination by specially qualified medicalmen appointed by, or acting under, the authority of the contractingState.

(2) Medical supervision, both for the selection and the main-tenance of efficiency, shall be based upon certain requirements ofmental and physical fitness. The aeronaut must neither sufferfrom any wound, injury, or operation, nor possess any abnor-mality, congenital or otherwise, which will interfere with theefficient and safe handling of aircraft. Nor may he suffer fromany disease or disability which renders him liable suddenly tobecome incompetent in the management of aircraft. He must,therefore, possess heart, lungs, kidneys and nervous system capableof withstanding the effects of altitudes and also the effects of pro-longed flight. Further, the aeronaut must possess j1 degree ofvisual and auditory acuity compatible with the efficient perform-ance of his duties, and also possess free nasal air entry on eitherside.

The Convention, further, has provided that for thepresent each contracting State shall fix its own methodof examination until the authorised medical representa-tives of an International Commission for air naviga-tion shall decide on tests and standards. In order toensure the maintenance of efficiency the aeronaut is tobe re-examined every six months and the findingsattached to his original record. In case of illness oraccident there is also a re-examination, and no aeronautmay resume duty before being pronounced fit. More-over, the date and result of each re-examination isrecorded on the certificate. Lastly, the Convention pro-vides that each contracting State may raise the standardsas they like, but cannot lower them.

The British llTethods of Examination.The pamphlet describes the British methods for the

examination of flying-men in compliance with inter-national medical requirements. The American AirService has issued a full and profusely illustratedmanual of the national procedure, and it is none toosoon that the same is now done in this country. Thephysical and temperamental suitability of candidatesfor aviation engaged during the war the earnest atten-tion of British doctors and physiologists, as in France,Italy, the United States, and Germany, and the desireof the Royal Air Force is to issue some pattern ofgeneral guidance for the future, having regard to thelessons of the past.The pamphlet then sets out in paragraph form certain

instructions taken verbatim from those issued to themedical officers of the Royal Air Force for the examina-tion of aviation candidates. The special flying tests,which for a long time were carried out separately, fall

AN explanation of the methods and standards now inuse in this country for the examination of applicantsfor licences as civilian airmen was published, at theend of last week, under the authority of the Air Council.The Dominions and Colonies, who are now about to putinto practice the principles laid down in the Inter-national Air Convention, have been especially in the eyeof the Air Council in issuing a valuable brochure, but allthe medical profession, and, indeed, the public, willbenefit by learning the careful procedure whereby theintending aeronaut is selected for his dangerous andresponsible career.The pamphlet begins by reference to the

Interncetionab MecMca-! Requirements for Air Navigation.An extract from the Convention relating to Inter-

national Air Navigation, 1919, is quoted, setting out thatthe requirements are that pilots and navigators engagedin public transport shall be 19 years of age, of goodfamily and personal history, free from mental, moral,or physical defect or hereditary nervous instability, andable to reach the standards required at a generalmedical and surgical examination and also at examina-tions into special sense acuity. The InternationalConvention sets out that-

(1) Every candidate before obtaining a licence as a pilot,navigator, or engineer of aircraft engaged in public transport shallpresent himself for examination by specially qualified medicalmen appointed by, or acting under, the authority of the contractingState.

(2) Medical supervision, both for the selection and the main-tenance of efficiency, shall be based upon certain requirements ofmental and physical fitness. The aeronaut must neither sufferfrom any wound, injury, or operation, nor possess any abnor-mality, congenital or otherwise, which will interfere with theefficient and safe handling of aircraft. Nor may he suffer fromany disease or disability which renders him liable suddenly tobecome incompetent in the management of aircraft. He must,therefore, possess heart, lungs, kidneys and nervous system capableof withstanding the effects of altitudes and also the effects of pro-longed flight. Further, the aeronaut must possess j1 degree ofvisual and auditory acuity compatible with the efficient perform-ance of his duties, and also possess free nasal air entry on eitherside.

The Convention, further, has provided that for thepresent each contracting State shall fix its own methodof examination until the authorised medical representa-tives of an International Commission for air naviga-tion shall decide on tests and standards. In order toensure the maintenance of efficiency the aeronaut is tobe re-examined every six months and the findingsattached to his original record. In case of illness oraccident there is also a re-examination, and no aeronautmay resume duty before being pronounced fit. More-over, the date and result of each re-examination isrecorded on the certificate. Lastly, the Convention pro-vides that each contracting State may raise the standardsas they like, but cannot lower them.

The British llTethods of Examination.The pamphlet describes the British methods for the

examination of flying-men in compliance with inter-national medical requirements. The American AirService has issued a full and profusely illustratedmanual of the national procedure, and it is none toosoon that the same is now done in this country. Thephysical and temperamental suitability of candidatesfor aviation engaged during the war the earnest atten-tion of British doctors and physiologists, as in France,Italy, the United States, and Germany, and the desireof the Royal Air Force is to issue some pattern ofgeneral guidance for the future, having regard to thelessons of the past.The pamphlet then sets out in paragraph form certain

instructions taken verbatim from those issued to themedical officers of the Royal Air Force for the examina-tion of aviation candidates. The special flying tests,which for a long time were carried out separately, fall

1 The Medical Examination of Civilian Pilots, Navigators, and Engineers. London: His Majesty’s Stationery Office. 1920. To be purchased through any Bookseller or directly from H.M. StationeryOffice, 6d, net.

for examination under the heading of the differentsystems to which they apply. The mental tests are notincluded, not because they are considered useless, butrather, it would seem, because it is better to leave theircharacter to the discretion of the examiner; and thesame may be said of special reaction-time tests or

muscle-tone tests, which have not been adopted in thiscountry to any large extent because further investiga-tion is needed.The methods of examination are then carefully

described under the headings of family and personalhistory, age, general surgical examination, generalmedical examination, and special examinations of theeye, ear and vestibular apparatus, nose, and throat.Under the head of personal history, the following con-ditions are considered to require special mention :-Head.-A history of fracture of the skull should definitely dis-

qualify for air work.Neck.-Scars, the result of removal of glands, should not be held

as a cause for rejection, but the time which has elapsed sinceoperation, the question of recurrence and signs of tubercle else-where, are all points needing attention and examination.Chest.-In cases of perforating wounds of the lungs, any signs of

permanent injury to the lung tissue, while not necessarily con-stituting a cause for rejection, will indicate the need for specialcare with the tests for respiratory efficiency. A history of empyema,with resection of rib, calls for careful consideration of the cause ofthe condition and its effect on the lung expansion.Extremities.-Applicants suffering from the conditions mentioned

below should not be accepted: (1) Amputation of thumb at carpo-metacarpal joint; (2) amputation of first and second fingers ;(3) amputation of hand or arm; (4) injuries or operations leavingmarked limitation of movement; (5) amputation of the leg abovethe knee; (6) operations on the knee-joints, which have resulted insuch limitations of movement at the joint as to interfere with theproper control of the machine.Note.-Amputations below the knee are not necessarily disabling,

provided the movement at the knee-joint is free ; each case shouldbe considered on its merits.In addition to the above, injuries which involve the trunks of the

larger nerves, resulting in paresis, or which leave scars causingpain or cramp, are sufficient cause for rejection.Abdominal operations.-The fact of an abdominal operation

having been performed should not, in itself, disqualify an applicantor airman, provided that no hernial protrusion or marked weaknessof the abdominal wall has resulted.A histbry of tuberculous disease of joints or bones, recent or

remote, should disqualify.A dislocated semilunar cartilage may prove a permanent dis-

ability, even after so-called successful operative treatment.

In respect of habits, the consensus of opinion is infavour of the strictest moderation in tobacco and alcohol

among flying-men. Any subject with a tendency tocardio-vascular or nervous instability should thereforebe strongly advised in this direction, but gradual renun-ciation is probably more expedient in most cases thansudden and total abstention. The following is the textof the pamphlet:-

SwoMMSL—It is recommended that careful record should be madeas to whether "non-smoker" or "smoker," and, if the latter,whether pipes or cigarettes, or both, and whether moderate orexcessive. The simplest method is to make a note such as C 10 orP 3-i.e., ten cigarettes or three pipes per day.Alcohol.-Questions under this head should elicit whether

teetotaller or "takes alcohol." If the latter, the form, e.g., spirits,wines, beer, or cocktails, and the records should give some idea ofthe average daily quantity.Venereal disease.-Any applicant or airman with a history of

syphilitic disease should be deferred, and referred to an expert foran opinion before granting or renewing a licence.Sleep.-Enquiry should be made as to hours of sleep, the occur-

rence of dreams, nightmares, &c. If sleep is poor, questions shouldbe put as to the difficulty of getting to sleep, and the records shouldshow the number of hours slept.

Athletic proficiency and familiarity with unsedentarypursuits will gain marks, as, of course, will a historyof previous flying work. The minimum age of 19, asordained by the International Convention is adopted,but no maximum age is suggested.We need not put out the details of the general

surgical examination and general medical examination,because all those who have to conduct the examina-tion are certain to be familiar with them, but it is

interesting to see how valuable the methods of bodymeasurement advocated by Professor G. Dreyer in ourcolumns have proved themselves. It is consideredthat these methods provide an accurate means ofestimating physical proportions, and should be appliedpractically at each examination and re-examination.

The Examination of the Respira,tory System.The examination methods for discovering the condi-

for examination under the heading of the differentsystems to which they apply. The mental tests are notincluded, not because they are considered useless, butrather, it would seem, because it is better to leave theircharacter to the discretion of the examiner; and thesame may be said of special reaction-time tests or

muscle-tone tests, which have not been adopted in thiscountry to any large extent because further investiga-tion is needed.The methods of examination are then carefully

described under the headings of family and personalhistory, age, general surgical examination, generalmedical examination, and special examinations of theeye, ear and vestibular apparatus, nose, and throat.Under the head of personal history, the following con-ditions are considered to require special mention :-Head.-A history of fracture of the skull should definitely dis-

qualify for air work.Neck.-Scars, the result of removal of glands, should not be held

as a cause for rejection, but the time which has elapsed sinceoperation, the question of recurrence and signs of tubercle else-where, are all points needing attention and examination.Chest.-In cases of perforating wounds of the lungs, any signs of

permanent injury to the lung tissue, while not necessarily con-stituting a cause for rejection, will indicate the need for specialcare with the tests for respiratory efficiency. A history of empyema,with resection of rib, calls for careful consideration of the cause ofthe condition and its effect on the lung expansion.Extremities.-Applicants suffering from the conditions mentioned

below should not be accepted: (1) Amputation of thumb at carpo-metacarpal joint; (2) amputation of first and second fingers ;(3) amputation of hand or arm; (4) injuries or operations leavingmarked limitation of movement; (5) amputation of the leg abovethe knee; (6) operations on the knee-joints, which have resulted insuch limitations of movement at the joint as to interfere with theproper control of the machine.Note.-Amputations below the knee are not necessarily disabling,

provided the movement at the knee-joint is free ; each case shouldbe considered on its merits.In addition to the above, injuries which involve the trunks of the

larger nerves, resulting in paresis, or which leave scars causingpain or cramp, are sufficient cause for rejection.Abdominal operations.-The fact of an abdominal operation

having been performed should not, in itself, disqualify an applicantor airman, provided that no hernial protrusion or marked weaknessof the abdominal wall has resulted.A histbry of tuberculous disease of joints or bones, recent or

remote, should disqualify.A dislocated semilunar cartilage may prove a permanent dis-

ability, even after so-called successful operative treatment.

In respect of habits, the consensus of opinion is infavour of the strictest moderation in tobacco and alcohol

among flying-men. Any subject with a tendency tocardio-vascular or nervous instability should thereforebe strongly advised in this direction, but gradual renun-ciation is probably more expedient in most cases thansudden and total abstention. The following is the textof the pamphlet:-

SwoMMSL—It is recommended that careful record should be madeas to whether "non-smoker" or "smoker," and, if the latter,whether pipes or cigarettes, or both, and whether moderate orexcessive. The simplest method is to make a note such as C 10 orP 3-i.e., ten cigarettes or three pipes per day.Alcohol.-Questions under this head should elicit whether

teetotaller or "takes alcohol." If the latter, the form, e.g., spirits,wines, beer, or cocktails, and the records should give some idea ofthe average daily quantity.Venereal disease.-Any applicant or airman with a history of

syphilitic disease should be deferred, and referred to an expert foran opinion before granting or renewing a licence.Sleep.-Enquiry should be made as to hours of sleep, the occur-

rence of dreams, nightmares, &c. If sleep is poor, questions shouldbe put as to the difficulty of getting to sleep, and the records shouldshow the number of hours slept.

Athletic proficiency and familiarity with unsedentarypursuits will gain marks, as, of course, will a historyof previous flying work. The minimum age of 19, asordained by the International Convention is adopted,but no maximum age is suggested.We need not put out the details of the general

surgical examination and general medical examination,because all those who have to conduct the examina-tion are certain to be familiar with them, but it is

interesting to see how valuable the methods of bodymeasurement advocated by Professor G. Dreyer in ourcolumns have proved themselves. It is consideredthat these methods provide an accurate means ofestimating physical proportions, and should be appliedpractically at each examination and re-examination.

The Examination of the Respira,tory System.The examination methods for discovering the condi-

2 THE LANCET, August 9th, 1919, p. 227.

976

tions of the respiratory system of aviators may be

quoted verbatim :-(i.) Conàition of !MM6.—Evidence of chronic bronchitis, emphy-

sema, or tuberculous lesions (quiescent or active) should absolutelydisqualify an applicant. An applicant should not be accepted as apilot if the chest expansion as a whole is bad, especially if thedeficiency is due to malformation of the chest wall.

(ii.) Breath ?M)!<KM0.&mdash;(Apparatus required: stopwatch and nose-clip.) The subject is asked to expire as deeply as possible (prefer-ably audibly) and then to fill the lungs fully (but hot to absolutedistension), and to hold the breath with the nose clipped or held.The reason for the audible expiration is that it has been observedthat some subjects suffering from stress have lost the power ofexpiring fully, and a marked shortening of time taken to expire asfully as possible may afford an indication of such loss of power.The time during which the breath is held is noted, and the subjectis then asked the reason for giving up. This should be recorded.The significance of the test and the time that is expected must notbe communicated, and on no account may any examinee timehimself.Reason for ce<MMt.&mdash;Normally an answer such as

"

I had to giveup," "I felt I should burst," I wanted to breathe" is given.Subjects suffering from marked disability at altitudes almostinvariably return an abnormal answer, e.g., "I became giddy ordizzy," ’ Things went blurred," " The blood rushed to mytemples," " I began to feel squeamish." Where the answer isdeomed not to be normal the subject’s own words should beL1VPT7.

tions of the respiratory system of aviators may be

quoted verbatim :-(i.) Con&agrave;ition of !MM6.&mdash;Evidence of chronic bronchitis, emphy-

sema, or tuberculous lesions (quiescent or active) should absolutelydisqualify an applicant. An applicant should not be accepted as apilot if the chest expansion as a whole is bad, especially if thedeficiency is due to malformation of the chest wall.

(ii.) Breath ?M)!<KM0.&mdash;(Apparatus required: stopwatch and nose-clip.) The subject is asked to expire as deeply as possible (prefer-ably audibly) and then to fill the lungs fully (but hot to absolutedistension), and to hold the breath with the nose clipped or held.The reason for the audible expiration is that it has been observedthat some subjects suffering from stress have lost the power ofexpiring fully, and a marked shortening of time taken to expire asfully as possible may afford an indication of such loss of power.The time during which the breath is held is noted, and the subjectis then asked the reason for giving up. This should be recorded.The significance of the test and the time that is expected must notbe communicated, and on no account may any examinee timehimself.Reason for ce<MMt.&mdash;Normally an answer such as

"

I had to giveup," "I felt I should burst," I wanted to breathe" is given.Subjects suffering from marked disability at altitudes almostinvariably return an abnormal answer, e.g., "I became giddy ordizzy," ’ Things went blurred," " The blood rushed to mytemples," " I began to feel squeamish." Where the answer isdeomed not to be normal the subject’s own words should beL1VPT7.The average time the breath is held by the normal fit pilot is

69 seconds, the minimum time being 45 seconds. Generallyspeaking, a man who does not hold his breath 45 seconds shouldnot be admitted as a pilot. As a matter of experience it will befound that very nearly all such cases will be rejected on medicalgrounds, apart from this test. The test is believed to affordindication of : (a) The stability of the respiratory centre, andindirectly of the nervous system generally. (b) The likelihood(when the time is short and an abnormal answer is given) of thesubject suffering from oxygen-want at altitudes. (c) Resolution tocarry on " under conditions of stress.

(iii.) Expiratorp f01’Ce.-(Apparatus required: Mercury U tube.)The applicant or airman is asked to hold his cheeks withthe thumb and forefinger of the left hand, and steadily toblow the mercury column of the standard U tube up as high aspossible with the scale turned away. Several mouth-pieces shouldbe kept in disinfectant and carefully cleaned for each subject. Onno account must the applicant or airman be allowed to swing themercury up violently, and in all cases the height of any initialswing is to be disregarded. The reason for holding the cheeks isthat it has been found that in some cases the mercury maybe forced up to abnormal heights by the action of the cheekmuscles. The number of mm. Hg blown is recorded. Theexaminee is then asked to repeat the performance whilelooking at the column. The resolute subject may, under theseconditions, considerably pass the effort which he did not see, inthis way affording some indication of his mental make-up. On theother hand, a subject who is not trying may give very discrepantreadings. With the manometer again turned away, he may, byencouragement, be made to surpass his previous efforts. Butattempts made whilst looking at the manometer scale, will, if heis not really trying, fail to surpass previous efforts which hehas seen.

The average time the breath is held by the normal fit pilot is69 seconds, the minimum time being 45 seconds. Generallyspeaking, a man who does not hold his breath 45 seconds shouldnot be admitted as a pilot. As a matter of experience it will befound that very nearly all such cases will be rejected on medicalgrounds, apart from this test. The test is believed to affordindication of : (a) The stability of the respiratory centre, andindirectly of the nervous system generally. (b) The likelihood(when the time is short and an abnormal answer is given) of thesubject suffering from oxygen-want at altitudes. (c) Resolution tocarry on " under conditions of stress.

(iii.) Expiratorp f01’Ce.-(Apparatus required: Mercury U tube.)The applicant or airman is asked to hold his cheeks withthe thumb and forefinger of the left hand, and steadily toblow the mercury column of the standard U tube up as high aspossible with the scale turned away. Several mouth-pieces shouldbe kept in disinfectant and carefully cleaned for each subject. Onno account must the applicant or airman be allowed to swing themercury up violently, and in all cases the height of any initialswing is to be disregarded. The reason for holding the cheeks isthat it has been found that in some cases the mercury maybe forced up to abnormal heights by the action of the cheekmuscles. The number of mm. Hg blown is recorded. Theexaminee is then asked to repeat the performance whilelooking at the column. The resolute subject may, under theseconditions, considerably pass the effort which he did not see, inthis way affording some indication of his mental make-up. On theother hand, a subject who is not trying may give very discrepantreadings. With the manometer again turned away, he may, byencouragement, be made to surpass his previous efforts. Butattempts made whilst looking at the manometer scale, will, if heis not really trying, fail to surpass previous efforts which hehas seen.The average for normal individuals is about 105 mm. Hg. When

under 80 mm. Hg it suggests that the subject will probably beincapable of sustained effort in routine aerial work and shouldprobably be rejected. The test, however, should be taken in con-junction with the results of the rest of the examination.

(iv.) Fatigue test and pulse ?’es.poMM.&mdash;(Apparatus is given.) Thistest is performed as follows. The applicant is asked to empty thelungs, fill up, blow the mercury in the U tube to the height of40 mm. and hold it there without breathing for as long as possible,the nose being clipped. The average time in the large number ofcases tested is 50 seconds: below 40 seconds is unsatisfactory. Anessential adjunct to this test is the behaviour of the pulse, whichis counted every five seconds during the time that the mercury issustained. Starting at the fifth second in the normal individualthere is generally a steady slow rise in the rate of the pulse, or afairly marked rise, which is sustained most of the time. Forexample, the pulse-rate may rise gradually from 72 to 96 or 108,according to the time the breath is held, or the pulse may risealmost at once from 72 to 96 or 108, and may be sustained there. Alarge rise in rate-eg., from 72 to 132 or 144-is unsatisfactory. Incases of stress a characteristic response is for the pulse to jump upto a quick rate during the fifth to the tenth or fifteenth seconds,and then to fall away in rate to normal or even below normal.Such a response is as follows: Normal at start, 84; 5th-lOth

second, 144-sometimes almost impalpable; falling away (say 20-25seconds) to 72 or even 60. Such cardiometer instability is an adversefactor in aerial work and is an indication for rejection. Otherpoints in the examination should, however, be taken into considera-tion. The test is to be recorded by first noting the number ofseconds during which the mercury column is sustained, and thenwriting down the pulse-rate of 5 second intervals, e.g., 50-P.6677789888, the time taken to blow the mercury to 40 mm. beingignored.This test affords information as to the stability of the medullary

centres and of the power of resistance to fatigue.(v.) Flack’s bag test and Dreyer’s nit?’ogen test.-Although these

tests have proved themselves of great value detailed descriptionsare not included here, partly because the, time taken to apply themproperly is considerable, and partly because they really require tobe worked by trained physiologists. In the case of the Dreyer test,the apparatus is expensive and, at present, difficult to obtain.Should information be required as to the method of their use andresults obtained, reference should be made to the publications of theAir Medical Investigations Subcommittee of the Medical ResearchCommittee, Nos. 1, 2, and 5.

(To be continued,)

The average for normal individuals is about 105 mm. Hg. Whenunder 80 mm. Hg it suggests that the subject will probably beincapable of sustained effort in routine aerial work and shouldprobably be rejected. The test, however, should be taken in con-junction with the results of the rest of the examination.

(iv.) Fatigue test and pulse ?’es.poMM.&mdash;(Apparatus is given.) Thistest is performed as follows. The applicant is asked to empty thelungs, fill up, blow the mercury in the U tube to the height of40 mm. and hold it there without breathing for as long as possible,the nose being clipped. The average time in the large number ofcases tested is 50 seconds: below 40 seconds is unsatisfactory. Anessential adjunct to this test is the behaviour of the pulse, whichis counted every five seconds during the time that the mercury issustained. Starting at the fifth second in the normal individualthere is generally a steady slow rise in the rate of the pulse, or afairly marked rise, which is sustained most of the time. Forexample, the pulse-rate may rise gradually from 72 to 96 or 108,according to the time the breath is held, or the pulse may risealmost at once from 72 to 96 or 108, and may be sustained there. Alarge rise in rate-eg., from 72 to 132 or 144-is unsatisfactory. Incases of stress a characteristic response is for the pulse to jump upto a quick rate during the fifth to the tenth or fifteenth seconds,and then to fall away in rate to normal or even below normal.Such a response is as follows: Normal at start, 84; 5th-lOth

second, 144-sometimes almost impalpable; falling away (say 20-25seconds) to 72 or even 60. Such cardiometer instability is an adversefactor in aerial work and is an indication for rejection. Otherpoints in the examination should, however, be taken into considera-tion. The test is to be recorded by first noting the number ofseconds during which the mercury column is sustained, and thenwriting down the pulse-rate of 5 second intervals, e.g., 50-P.6677789888, the time taken to blow the mercury to 40 mm. beingignored.This test affords information as to the stability of the medullary

centres and of the power of resistance to fatigue.(v.) Flack’s bag test and Dreyer’s nit?’ogen test.-Although these

tests have proved themselves of great value detailed descriptionsare not included here, partly because the, time taken to apply themproperly is considerable, and partly because they really require tobe worked by trained physiologists. In the case of the Dreyer test,the apparatus is expensive and, at present, difficult to obtain.Should information be required as to the method of their use andresults obtained, reference should be made to the publications of theAir Medical Investigations Subcommittee of the Medical ResearchCommittee, Nos. 1, 2, and 5.

(To be continued,)

CHICAGO HEALTH REPORT.*

CHICAGO, which only had one white settler in 1804,and a population of 7,580 in 1843, is now a city of

2,596,681 souls, covering an area of 190 square miles,and increasing at the rate of 50,000 a year. Fifty-oneper cent. of the population consists of males, and 97’9per cent. are white men. As regards race, 62 per cent.were born in the United States, 14 per cent. in Germanyand Austria, 6 per cent. in Russia, and 3 per cent. inIreland. In 1918 the death-rate was 17’17 and thebirth-rate 24’5 per 1000. But the latter figure is only arough estimate, for birth registration has only beenrecently established, and in 1914 the reported birthswere 13,000 below the estimated. Accordingly, infantiledeath-rates are given in terms of total deaths, not ofbirths. In 1918 14 per cent. of total deaths were under1 year of age, which is 98 per 1000 of estimated births.The general death-rate, owing to the influenza epidemic,was the highest recorded since 1895, but infantile mor-tality was much less affected by the epidemic than thegeneral mortality.

CHICAGO, which only had one white settler in 1804,and a population of 7,580 in 1843, is now a city of

2,596,681 souls, covering an area of 190 square miles,and increasing at the rate of 50,000 a year. Fifty-oneper cent. of the population consists of males, and 97’9per cent. are white men. As regards race, 62 per cent.were born in the United States, 14 per cent. in Germanyand Austria, 6 per cent. in Russia, and 3 per cent. inIreland. In 1918 the death-rate was 17’17 and thebirth-rate 24’5 per 1000. But the latter figure is only arough estimate, for birth registration has only beenrecently established, and in 1914 the reported birthswere 13,000 below the estimated. Accordingly, infantiledeath-rates are given in terms of total deaths, not ofbirths. In 1918 14 per cent. of total deaths were under1 year of age, which is 98 per 1000 of estimated births.The general death-rate, owing to the influenza epidemic,was the highest recorded since 1895, but infantile mor-tality was much less affected by the epidemic than thegeneral mortality.

Fnnctions of the C01Jt1nission61’ of Health.The office of Commissioner of Health differs materially

from that of the English medical officer of heath. Thecommissioner is the administrative head of theDepartment of Health, and is charged with theenforcement of all laws of the State, ordinancesof the city of Chicago, and all rules and regula-tions of the Department of Health relating to thesanitary condition of the city. Infectious hospitals,public baths, laundries, and other health institutionsare under him, and he is authorised to publish informa-tion concerning his work, the health of the community,and methods of preventing diseases. He thus combines,as regards public health, the functions of healthcommittee, town clerk, and Asylums Board, with thoseof medical officer of health, and exercises more

arbitrary power than any of these. He is responsibleonly to the mayor. Under him are an Assistant Com-missioner and seven distinct bureaux, dealing respec-tively with (1) general administration, education, andpublicity ; (2) municipal laboratory ; (3) medical inspec-tion, including infectious disease, school hygiene, infantwelfare, and day nurseries; (4) food inspection, withlicensing of milk and food dealers ; (5) birth and deathregistration and vital statistics; (6) sanitation, plumb-ing, housing, new buildings, public baths, and comfortstations; (7) isolation hospitals and ambulance service.Each bureau is under a bureau chief directly responsibleto the Commissioner of Health. In addition to thesebureaux which are directly under him, the Commis-sioner is the president or director of six correlatedhealth agencies which work in cooperation with hisdepartment-viz., the Public Health Association, theCommission of Ventilation, ther Tuberculosis Sani-tarium, the Morals Commission, Board of Examiners ofPlumbers, and Chicago School of Sanitary Instruction.The Bureau of Vital Statistics controls funerals, under-

takers, and cemeteries, and apparently depends moreon this control than on the certificates of physicians forthe reports of deaths. At any rate, statistics of deathsare said to have been complete since 1871.For the control of infectious diseases the’ city is

divided into 55 districts, with a health officer overeach. He is required to inspect and quarantine allreported cases of diphtheria, scarlet fever, measles,mumps, and other infectious diseases. Cases of small-pox, typhoid fever, and infantile paralysis are at onceremoved to hospital and contacts kept under observation.

Fnnctions of the C01Jt1nission61’ of Health.The office of Commissioner of Health differs materially

from that of the English medical officer of heath. Thecommissioner is the administrative head of theDepartment of Health, and is charged with theenforcement of all laws of the State, ordinancesof the city of Chicago, and all rules and regula-tions of the Department of Health relating to thesanitary condition of the city. Infectious hospitals,public baths, laundries, and other health institutionsare under him, and he is authorised to publish informa-tion concerning his work, the health of the community,and methods of preventing diseases. He thus combines,as regards public health, the functions of healthcommittee, town clerk, and Asylums Board, with thoseof medical officer of health, and exercises more

arbitrary power than any of these. He is responsibleonly to the mayor. Under him are an Assistant Com-missioner and seven distinct bureaux, dealing respec-tively with (1) general administration, education, andpublicity ; (2) municipal laboratory ; (3) medical inspec-tion, including infectious disease, school hygiene, infantwelfare, and day nurseries; (4) food inspection, withlicensing of milk and food dealers ; (5) birth and deathregistration and vital statistics; (6) sanitation, plumb-ing, housing, new buildings, public baths, and comfortstations; (7) isolation hospitals and ambulance service.Each bureau is under a bureau chief directly responsibleto the Commissioner of Health. In addition to thesebureaux which are directly under him, the Commis-sioner is the president or director of six correlatedhealth agencies which work in cooperation with hisdepartment-viz., the Public Health Association, theCommission of Ventilation, ther Tuberculosis Sani-tarium, the Morals Commission, Board of Examiners ofPlumbers, and Chicago School of Sanitary Instruction.The Bureau of Vital Statistics controls funerals, under-

takers, and cemeteries, and apparently depends moreon this control than on the certificates of physicians forthe reports of deaths. At any rate, statistics of deathsare said to have been complete since 1871.For the control of infectious diseases the’ city is

divided into 55 districts, with a health officer overeach. He is required to inspect and quarantine allreported cases of diphtheria, scarlet fever, measles,mumps, and other infectious diseases. Cases of small-pox, typhoid fever, and infantile paralysis are at onceremoved to hospital and contacts kept under observation.

School Hygiene and Infant Welfare.School hygiene and infant welfare are not separated

as in this country, but are both under an assistant bureauchief, who supervises the medical inspection of schoolchildren, open-air schools, and " open-window rooms’’ ,.

School Hygiene and Infant Welfare.School hygiene and infant welfare are not separated

as in this country, but are both under an assistant bureauchief, who supervises the medical inspection of schoolchildren, open-air schools, and " open-window rooms’’ ,.

* Report and Hand-book of the Department of Health of the Cityof Chicago for the years 1911 to 1918 inclusive. By John DillRobertson, M.D., Commissioner of Health. House of Severinghaus,2141-49, Ogden Avenue. 1919. Pp. 1535. $5.